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Source: United States House of Representatives – Congressman Roger Marshall (1st District of Kansas)

Legislation Would Streamline Prior Authorization Processes for Medicare Advantage Enrollees, Help Reduce Administrative Burden for Providers and Protect Seniors from Unnecessary Delays in Access to Treatment

WASHINGTON, D.C. – Today, U.S. Sens. Sherrod Brown (D-OH) and John Thune (R-SD) introduced the Improving Seniors’ Timely Access to Care Act, bipartisan legislation that  builds on legislation introduced in the U.S. House of Representatives last year by Reps. Roger Marshall (R-KS), Suzan DelBene (D-WA), Ami Bera (D-CA), and Mike Kelly (R-PA) and requires private insurance companies that operate Medicare Advantage (MA) plans to establish an electronic prior authorization (ePA) system to approve medical services in a more timely manner. Implementing an electronic authorization program will reduce delays and help older Americans get quicker access to the treatment and care they need. 

Prior authorization can play a role in ensuring beneficiaries receive clinically appropriate treatments and help control the cost of care. However, when used improperly, prior authorization can lead to delays in care for patients and result in administrative burdens for providers. The Improving Seniors’ Timely Access to Care Act would help to streamline prior authorization processes, and promote safe, timely, and affordable access to evidence-based care for Medicare Advantage enrollees and the providers and suppliers who care for them.

“As a physician in rural Kansas, my top priority was always to provide quality care to every patient,” said Rep. Roger Marshall, M.D. (R-KS). “I’ve carried that charge in Congress and helped introduce bipartisan legislation to modernize Medicare Advantage that will better serve America’s seniors. Over the past two years, my colleagues and I reviewed comments from nearly 450 national and state organizations. I am proud of our updated legislation and honored to have Senators John Thune and Sherrod Brown join us in this effort. This has been truly a bipartisan collaboration and I look forward to continue leading this charge next Congress.” 

Prior authorization is a tool used by insurers to prevent improper payments and reduce unnecessary care by requiring physicians and other health care professionals to get pre-approval for certain medical services. However, it’s not without fault. Each plan has a unique way of handling prior authorization, often requiring the faxing of a patient’s medical information or phone calls by clinicians, which takes precious time away from patient care and can potentially lead to a delay of needed medical intervention. In 2018, the U.S. Department of Health & Human Services’ Office of the Inspector General raised concerns after an audit revealed that MA plans ultimately approved 75% of requests that were originally denied.

Health plans and providers agree that the process can be improved and agreed on principles in a 2018 consensus statement. Building on these principles, the bill would improve the prior authorization process in MA plans by moving the process to an electronic standard as well as introduce automation efforts that will lead to real-time decision making. It would also ensure health care providers know exactly what information they need to submit to insurance plans when requesting prior authorization, reducing the time and effort spent corresponding and gaining an understanding of how the plans are making these decisions.

The policies of this bill will allow health care providers to focus on delivering quality patient care. Recognizing the importance of this issue, this legislation has gained support by over 400 organizations across the country.

The House version of the bill has the support of nearly 280 members of Congress and has garnered more than 420 endorsements from a diverse group of outside stakeholders.